=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235534934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AREA AGENCY ON AGING SERVING NAPA AND SOLANO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2014
-----------------------------------------------------
Last Update Date | 12/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 CONTRA COSTA ST
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-6352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-644-6612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 CONTRA COSTA ST
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-6352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-644-6612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | SARA PRYOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-644-6612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------